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How-to Guide for Accessing Insurance Coverage

If your child is diagnosed with a food allergy or severe GI condition, healthcare providers will often prescribe an amino acid-based formula. Most insurance providers consider these formulas to be “medical food” or medical equipment, and necessary for a child’s health and well-being.

You may need to contact your insurance company in order to identify which part of your policy provides coverage, as many providers do not include these formulas under the prescription plan and often claims are initially denied. Persistence and a basic understanding of insurance coverage may go a long way in helping secure coverage.

(Cambrooke also offers assistance in securing insurance reimbursement, see information at the end of this post or visit this link.)

Here are 5 Steps for Obtaining Insurance Coverage:

(Note that the information below was adapted based on guidance from the American Partnership for Eosinophilic Disorders – APFED – which can be found by visiting this link.)

1. Call your insurance provider to determine whether your plan includes coverage for elemental formulas.

Contact customer service and ask them whether your plan includes Durable Medical Equipment (DME) coverage for an elemental formula. They can then run a search for elemental formula or amino acid-based formula. If you have coverage, they will often ask you a series of questions since the coverage may be dependent on the use of a feeding tube or other types of restrictions. Coverage may also be limited to specific formula suppliers or vendors.

2. Determine your coverage specifications.

Once you have established that the formula your child needs is covered, it is important to determine whether you need to meet a deductible before your coverage can begin. If so, determine the co-pay amount or percentage that you may be required to pay and whether or not they will be applied toward your out-of-pocket maximum for the year.

3. Ask for a Nurse Case Manager who can help you navigate and access coverage.

While they may not be able to help you with claims that would be denied anyways, they may be helpful in expedite claims and helping you with the appeals process. Note that not all insurance companies can provide this extra level of support, but it is worth asking!

4. Identify the category that your claim falls under for an elemental formula.

Many insurance companies that cover amino acid-based formulas (note that they may refer to the category of these formulas – elemental formulas) may classify it as DME. Claims from pharmacies that are submitted as “pharmaceuticals” will generally be denied.

5. Use the appropriate ICD-10 code in your claim.

Ask your GI or allergy specialist to refer you to a DME supplier, and ask them to submit the claim using the ICD-10 code that is specific to your child’s condition.

State Insurance Mandates

Some states mandate coverage for elemental formulas for people who are on fully-insured plans as opposed to self-funded health plans, which are not subject to these same state law insurance mandates.

You can determine if you are eligible for formula coverage mandated by state law by first determining the state in which your plan was initiated (not your state of residence). You can access your plan’s documents with information on the state laws that bind your policy by contacting your insurance company directly.

Once you have determined the relevant state, you can access information on coverage that may be mandated by visiting this link.

Also, you may want to consider getting involved in pushing for formula legislation in individual states by sending an email to mailto:pac@apfed.org and they can connect you with volunteers.

Self-Insured Employer Plans

Another possible option for insurance coverage is through self-insured employer plans. Often, large companies and government entities have self-insured plans in which they contract with insurance companies to process claims and handle administrative tasks. The employer then pays the claims, and they have discretion regarding which services that will be covered.

You can contact customer service for your insurance provider to see if this is an option. You may also be able to talk to your Human Resources office and inform them that you are having trouble with your coverage and you want to seek their guidance. Often, there is an individual who handles medical insurance issues, and they may even be able to make exceptions for specific situations.

Medical Appeals

If you have exhausted all efforts to secure insurance coverage and your claims have been denied multiple times, you may want to file a medical appeal directly with your insurance company. Your physician and/or dietary specialist can be helpful in documenting the fact that the formula your child needs is a medical necessity. To start the process, reach out to your insurance provider to determine the process for filing a medical appeal and accessing the appropriate paperwork. MEDICAL FOODS & INSURANCE COVERAGE

CAMBROOKECare: A Pathway for Reimbursement Success

At a time when there are so many paths for medical food coverage, patients, caregivers, and dietitians are looking for choice, convenience, and compassion when it comes to managing a family’s medical food needs.

If you are concerned that your supplier will no longer carry your medical food products each month or that you may have to start paying a high percentage of your coinsurance for child’s formula each month, consider contacting CAMBROOKEcare™.

CLICK HERE TO REQUEST AN ENROLLMENT PACKAGE

DOWNLOAD THE LETTER OF MEDICAL NECESSITY

CAMBROOKEcare has a DEDICATED TEAM to support your efforts to obtain insurance reimbursement coverage. CAMBROOKEcare provides you with expanded reimbursement and coverage assistance you need today. This is a full-service program designed for one very important thing: helping you manage your family’s medical food coverage and reimbursement options.

You can apply to our Patient Assistance program when you have a financial hardship or insurance does not cover your child’s formula.

For more information, please visit this link or call 1 (833) 377-2773 or send an email to reimbursement@cambrooke.com.

Sources used in this article:

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